ENS 49237

v t e ENS Event
05:00 Aug 1, 2013
Title	Agreement State Report - Wrong Fractional Dose Administered to Patient
Event Description	The licensee reported the administration of a 700 cGy fractional dose instead of the 500 cGy prescribed fractional dose to a patient during GYN treatment on 8/1/13. The 700 cGy fraction was prepared for another patient. The isotope involved was Ir-192. The fraction was the second of a three fraction total dose of 1500 cGy. The final fraction will be adjusted so that the total dose to the patient is 1500 cGy. The prescribing physician had been informed. The patient will be informed of the adjustment prior to administration of the final fraction on 8/8/13. There are no anticipated adverse consequences to the patient. The cause is under investigation and the licensee is still discussing potential corrective actions. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 49237 +/-
Where
Iowa Health - Des Moines Des Moines, Iowa (NRC Region 3)
License number:	0310-1-77-HDR
Organization:	Iowa Department Of Public Health
Reporting

Agreement State
Time - Person (Reporting Time:+104.23 h4.343 days <br />0.62 weeks <br />0.143 months <br />)
Opened:	Leo Wardrobe 13:14 Aug 5, 2013
NRC Officer:	Pete Snyder
Last Updated:	Aug 5, 2013
49237 - NRC Website
v • d • e

v t e Emergency Notification System
Iowa Health - Des Moines with Agreement State
WEEKMONTHYEAR2013-08-01T05:00:00 [Table view]
[ENS list for Iowa Health - Des Moines]

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